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d*f f forba-- kip t'y 'QUALITYTESTING OF UNDERGROUND 7A1VkSATAFF0RD.9BLERATES, 416 2nd Street Galt, CA 95632 (209) 744-0112 FAX 744-0116 4 ' General Information— ac li'ty nformation-acility Name: wz , Ot7� �` liL Bldg.No.: Site Address: City: �00 zip: !&C3J® Facility Contact Person: 4114ek Contact Phone No.:( 20� ) $ef�,- -Z Make/Model of Monitoring System: Date of Testing/Servicing: 12- B. ZB. Inventory of Equipment Tested/Certified Check the ap2ro2riate boxes to indicate eciflc a ui ment inspected/serviced: Tank Gauging Probe. Model: / In-Tank Gauging Probe. Model: HA alar Space or Vault Sensor. Model: Zd ,®' ular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 7-0a Piping Sump/Trench Sensor(s). Model: 2,Oa ❑ pl Sump Sensor(s). Model: ❑ FW Sump Sensor(s). Model: Jff Mechanical Line Leak Detector. Model:_`?"��'P�16- Mechanical Line Leak Detector. Model:SrrP. - ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci ui ment a a and model in Section Eon Pa 2). ❑ Other(s ui ment a and model in Section E on Pae 2). Tsix�k ID: 0 cc-rr Tank ID: In-Tank Gauging Probe. Model:A - _ ❑ In-Tank Gauging Probe. Model: "Annular Space or Vault Sensor. Model: ZO 13Annular Space or Vault Sensor. .Model: �iping Sump/Trench Sensor(s). Model: 13Piping Sump/Trench Sensor(s). Model: 1311 Sump Sensor(s). Model: ❑ FillSump Sensor(s). Model: .O Mechanical Line Leak Detector. Model: $Tf•ML'P ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci a ui !n a.and model in Section E on P e 2). ❑ Other( eci a ui ment a and model in ection E on Pae 2). D' enser ID: 1 '+ 2- Dispenser ID: '� y- g ispenser Containment Sensor(s). Model: 7-0-S Dispenser Containment Sensor(s). Model: Zoa Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Di neer Containment Float(s)and Chain(s). Dis enser ID:_ .3 9}' Dispenser ID: ispenser Containment Sensor(s). Model: 2 08 ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: S� Dispenser ID: ispenser Containment Sensor(s). Model Z� ❑ Dispenser Containment sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis nser Containment Floats)and Chain(s). *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring e. - 'pment: For any a pment capable of generating such reports,I have also attached a copy of the report;(check all that apply): M.System set-up Alarm history report Technician Name(print):_ L?�nl f 1 i rnn Signatur . Certification No.: /Z E3 License.No.: T (t .�,Z,lo - L. T c� # o4q-)GIG Monitoring System Certification